Get It Share It Use It

Originally everybody loved the NPI mantra: Get It Share It Use It. But now people are having concerns about the sharing part. They are being inundated with letters, phone calls, and faxes asking us to provide our NPIs to other hospitals and clinics. Clinics really did not plan on having to hire extra staff to disseminate their NPIs to other providers all over the place. People were counting on the dissemination system!

Healthcare organizations are also restricting release of NPIs... They will only share with entities that can actually provide the name of the providers they want numbers for. Many of requests are coming in asking for all NPIs...which may be over 1600 providers in some cases. We believe that organizations should only be sharing with organizations that our providers have done business with...(for example some of those 1600 providers are dermatologists, hardly they would refer to say an OB/GYN clinic....Until there are more clear instructions from CMS/HHS nobody can be 100% sure on what should be sharing.

Some of the requests also are asking for organization IDs, and some are just confusing.

Here is an example of a letter that was received by some organization.
To: … Hospital "A"
From: Regional Clinic

In accordance with HIPAA, covered entities such as ours are required to obtain a new provider number called the NPI. We would like your assistance in providing us with your NPI, along with your current phone and fax numbers to ensure all the information we have on file for you is correct. Please submit to person name, email, phone. Attached is a list of our physician NPIs for your use.
Their list includes 20 individual (Type 1) provider NPIs and two org (Type 2) NPIs including their UPIN, phone and fax numbers.

All above raises lots of questions and concerns – how many providers are feeling this same burden? Are you responding to all requests? Do they think it should be restricted to only those who can be named (someone had referred to them at one point)? Is it correct to share your organization IDs with other providers?

NPI Sharing can be not necessary

CMS has put us in this difficult position, and there is no way out of it seen today. In wildest dreams thought people would be facing sending thousands of letters out to other providers, because nobody did imagine we would be so close to the deadline without a dissemination notice. However, that is the position we have been backed into.

Of course others can say - don't send the letters, because the payers are not going to be checking for referring providers. That is a very big risk to take (in A/R days) when you are the largest provider in the state. It only takes one large health plan turning on a tight edit to make a big, negative dent.

Even average providers are dealing with multiple requests for NPIs every week. They are also working with many smaller organizations in their state that need their numbers. If a provider tells they need a list of providers because they refer, and we need theirs, probably it to be ludicrous to refuse. It is not clear how anything at this point, other then providers sharing with providers, is going to help us out of this mess.

One of major payers was asked if they could share their list of collected NPis.....and they said this request is stuck in legal. From the sounds of it, the Dissemination Notice is stuck in legal. There is a certain familiar ring to that....

One more comment - if you don’t know the NPI, you don’t have to provide it. So...if they don’t ask, they don’t need it.

Story from the big healthcare facility - we just sent NPI requests letters out to 4,200 referring physicians this last week. We also requested their taxonomy codes. We have received many responses that do not contain their taxonomy codes or asking what a taxonomy code is or if it is the same as the tax ID.

Part of our medical staff is employed by our Medical Center and we perform their billing. The other part of our medical staff has privileges to see patients at our facility, but are responsible for their own billing. Some of these physician offices are begining to contact us to request our medical center’s NPI, as they will need to enter it in the ‘Service Facility’ to identify our facility on their claims.

We too are not accepting blanket requests from other providers for all our NPIs. Since we don’t frequently refer patients to other facilities, so we are not receiving many blanket requests for all our individual NPIs.

NPI seems to cause more expenses than savings

Who is paying for all this increased work? If people can’t implement due to lack of dissemination then that’s a problem. "I was under the impression that HIPAA was supposed to reduce my administrative costs" – that’s what people usually say.

And they are exactly right. The patients are going to pay, or employers, because this takes time and people.

Many providers also don’t know about the check digit, so they are putting miskeyed NPIs into their system because they don’t have any online system to verify against. That will eventually result in delayed claims.

Escalation of the NPI sharing problem

Some organizations also received significant pushback from the out-of-state "data dump" requestors. The requestor not only required a full download of all NPIs, they wanted hard-copies of the confirmation letters. After a bit of homework, organizatinos ascertained that they had submitted one test to them in the last 2 or 3 years (not a standard transaction). The response was: We are not permitted to disseminate Type 1 NPIs in our possession. The Dissemination Notice has not been published. The NPIs in our possession were disclosed to us, we did not apply for them on our providers’ behalf. We do not have the confirmation letters requested. Referencing the guidance that is available, it seems clear we do not have the authority to provide you with a download of those NPIs. We do not own the NPIs you have requested; the NPI Final Rule clearly states the provider is the owner of that identifier. If you have specific providers in this region for which you need NPIs, please contact them directly. Please note: we are paraphrasing here, this language should not be considered "legally approved language".

A lot of hospitals are hitting the same issue and have been dealing with it since January. They are flooded with calls, faxes, letters, you name it, asking for:

All of our Type 1 NPIs

All of our Type 2 NPIs

Either 1 or 2 or both...

They have a list of 100s of places/individuals asking for our NPIs. Some wanting it all, some wanting some, some wanting site specific, some want it faxed, some over the phone, over email and even snail mailed.

How in the world can a provider organization manage all of this? Whether you’re small or large, the number of requests impacts anyone and everyone, except health plans since we don’t have the National Plan Identifier yet...

Other providers calling for this are looking for either the Referring, Ordering, Prescribing, "Secondary" Type 1s, or else the Service Facility level NPI for the Type 2s.

Now, the understanding of the HIPAA IGs and pre-NPI of the transactions was this: For those scenarios listed above, if you have those situations, the loop/information in the required fields are required (i.e. Name). But when you read down into some of the element, such as identifiers, it’s sent if known. That’s how business is done today, and people rarely have to send identifiers in these fields, it’s not as critical to do business in today’s world. If it was, they’d have edits and processes in place to collect it for all the locations in our tables...

We also know that some health plans have business needs/requirements for adjudication for these. So if one payer does it, hmmm, wonder which one, then it basically becomes something needed by all since that payer is typically most provider’s bulk of volume.

According to CMS FAQ 5816 (Which was updated on 12/12/2006) the "guidance" says that the IGs were drafted prior to knowledge of how NPI works - true. But the guidance probably, made the wrong assumption that we’d be able to collect this data somehow easily (Say the data dissemination notice or NPI Registry dream). The FAQ gave the impression that if it a provider (Whether Type 1 or Type 2) has been assigned a NPI, you’re required to send it. Who knows if a provider has a NPI
Since we don’t have access to NPPES to validate who has one OR have a way to look up a NPI in a NPI Registry in the future if that doesn’t happen, this is going to be HUGE A/R impact and denials as far as I’m concern. If you think the generic OTH000 or RES000 when that was going to go away was going to be a problem, watch for NPI...

Two points of view on the NPI sharing issue

If we make the assumption that none of my health plans are going to verify, much less need these NPIs...then I can quit worrying, because we have been very successful in collecting medical staff and/or employed providers NPIs.

If we make the assumption that at least one our major health plans is going to need the NPI in secondary situations, then we need to make a major effort to go after referring providers, because we can’t assume that we know all of the providers who are going to be billed against that health plan (at least on the facility side.)

So, consider, for now, we have taken a list of 15,000 providers without NPIs and narrowed the list to providers in our and border states. We are eliminating duplicates, and trying to send multiple requests (for large provider groups) in one letter. We are going to ask other providers to send us the NPI in any way they can (email, fax, phone, snail mail, direct data entry into a website.) And, when we are contacted by other providers who ask us to share, we are doing our best.

And that creates a huge effort for all parties.

NCPDP usage of NPI

NCPDP believes it is the entity that should provide a solution for entities like pharmacies looking for NPIs of prescribers. There is a relational database of prescribers now (without NPIs but with other numbers, demographic information) and some organizations are building an online lookup. It is being tested now. The intent is that it will have NPIs of individuals that prescribe (and presumably also refer). Go to http://www.geoaccess.com/ncpdp/po/begin.asp

NCPDP plans to have the database commercially available by June 1 and development organizations intend on populating it with NPIs from NPPES or, if not available, private data sources (which will take more time). We much prefer NPPES due to the verification issue and NPPES is considered a primary data source which in the database world is the holy grail. Even the provider themselves is a secondary source as we know they make mistakes unless you have a copy of the NPI notification letter.

NCPDP will license use of this database on a per subscription basis and plans to only make NPIs available to covered entities.

Perhaps the American Hospital Association or other associations that already have databases of providers can make them commercially available with little additional expense by adding NPIs, I don’t know. It would seem professional associations are trusted by their members.